Provider Demographics
NPI:1598154890
Name:CHARLES VARGHESE M D
Entity Type:Organization
Organization Name:CHARLES VARGHESE M D
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:VARGHESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-209-5518
Mailing Address - Street 1:782 SW SISTERS WELCOME RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0442
Mailing Address - Country:US
Mailing Address - Phone:386-755-4518
Mailing Address - Fax:386-758-4500
Practice Address - Street 1:782 SW SISTERS WELCOME RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0442
Practice Address - Country:US
Practice Address - Phone:386-755-4518
Practice Address - Fax:386-758-4500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-10
Last Update Date:2015-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67182261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty